Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach the timing of DMARD initiation in patients with active RA who are on treatment for latent TB?
As the patient is already treated for latent TB, if they have not initiated DMARD therapy for RA, I would follow the guidelines and start conventional DMARD therapy. If the patient requires additional therapy because of insufficient response, I would choose a non-TNF inhibitor as the risk for TB rea...
Is omalizumab an option for a patient needing a specific antibiotic with an IgE-mediated reaction who continues to have reactions during a desensitization?
Omalizumab is FDA-approved for Asthma, Chronic spontaneous urticaria, chronic rhinosinusitis with nasal polyposis, and food allergy. It is a monoclonal antibody directed at IgE which will deplete circulating IgE and thus specific IgE on the mast cell and basophils will decrease. There is also likely...
How do you approach the management of persistent hyperphosphatemia in ESKD patients who are non-adherent to phosphate binders?
This is not easy. The first thing I usually do is try and find out why they are non-adherent. Is it due to side effects, cost, etc? Are there social reasons? For example, are they "embarrassed" to take binders if they are out eating with friends? Often, I find that I need to switch binders to see if...
Is it reasonable to consider the use of DOACs for LV thrombus management instead of coumadin?
I have no qualms whatsoever at using a DOAC instead of Vitamin K antagonist in this situation, provided that the patient doesn't have a mechanical valve. Endothelium is endothelium, so mechanistically I don't see much of a difference between using a DOAC to prevent/treat an LAA thrombus versus an LV...
What is the current recommendation for air travel after a primary spontaneous pneumothorax?
General guidelines including the British Thoracic Society recommend delaying air travel for at least 2 weeks following the radiographic resolution of a pneumothorax. However, recent studies have challenged this conservative approach. A study by Majercik et al., PMID 25494425 demonstrated that patien...
What are your management strategies for patients with recurrent nephrolithiasis and hypercalciuria who develop hypercalcemia after thiazide initiation?
My first concern is why. The thiazide may have unmasked primary hyperparathyroidism. I would get a PTH level plus serum phosphorus and vitamin D with a concurrent serum calcium to see if they are concordant. If not, it’s time to image the parathyroids. If no evidence of hyperparathyroidism, and hype...
Do you utilize urinary leukotrienes as a marker for initiation of montelukast?
No, I don’t. It is not readily available clinically and has not been shown to be predictive of response.
Do you recommend avoidance of vaginal estrogen in patients with SLE?
It depends on the age. The SELENA study demonstrated that BCPs in premenopausal women did not lead to flares or increased disease activity though the risk of increased clotting is an issue for APL+ folks. Post-menopausal women treated with HRT had an increase in mild flares compared to those not on ...
In your practice, when do you opt to treat unilateral primary hyperaldosteronism medically rather than surgically?
There should be a good reason for not pursuing surgery in a patient with unilateral primary aldosteronism. The surgery is more cost-effective. Some but not all data suggest a faster decrease in cardiovascular morbidity, a lower risk of atrial fibrillation, arterial stiffness, left ventricular mass, ...
Do you prefer still over carbonated water for your patients with recurrent nephrolithiasis who have chronically low urine volumes?
My main concern is hydration. Stone formers tend to be un-thirsty folks, and it is hard to get them to drink anything, let alone my minimum of 2L daily. Generally I recommend plain water; old research found no difference between hard and soft water. To the extent that carbonated water alkalinizes u...